Abstract: On September 5, 1996, Employee #1, a dock foreman, and five coworkers were in the lower rail yard of the Kaiser International Corporation. Kaiser International is a facility for the bulk handling of coal, and the lower yard is where the coal dumping process takes place. Rail cars, loaded with coal in the upper yard, are driven by a locomotive into a shed, which has a turning mechanism that flips the cars over. The cars are then pushed out of the shed and down a hill. At the bottom of the grade the car switches tracks goes back up another hi. It only climbs part way before gravity pulls the car down into the lower yard. Employee #1 and his coworkers had taken lunch at 12:00 p.m., and resumed work at 1:05 p.m. Thirteen cars had come down the track since the lunch break ended, at a rate of one car every two minutes. The yard's mechanic/electrician was preparing to give instructions to the swingman when he saw Employee #1's body lying on the tracks, approximately 32 ft away from the last boxcar. At the same time, the dump house operator sent the final car out of the dump house and down the grade. The electrician was about to pull Employee #1's body off the tracks when he was stopped by the lower yard man, who said it was too dangerous because another car was coming. Employee #1 was run over and killed. It was not clear what Employee #1 had been doing by the track. He was equipped with a shovel and radio at the time of the accident, and it is speculated that Employee #1 had been planning to dig around the switch. He was a new employee, hired out of Local 94 just three days before the accident. The causal factors for this accident include the employer's failure to implement and maintain a system for ensuring employees comply with safe and healthful work practices; the employer's failure to implement a system for communicating with workers on matters related to occupational safety and health; the employer's failure to train workers in safe work practices at the Kaiser International yard; and the employer's failure to put controls in place that would safeguard workers during rail car movement.